QOF data have revealed some mixed results for COPD during the contract’s first year. Dr Peter Saul explains how practices can improve care and maximise income
Of the 10 clinical areas in the quality and outcomes framework (QOF), practices have found chronic obstructive pulmonary disease (COPD) one of the most challenging, published QOF data have revealed.
Data from the North West Region, for example, show that practices have achieved an average of 86% of the 45 points available for COPD, the lowest percentage for any of the clinical areas.1 In Scotland, COPD ranks ninth out of the 10 clinical areas for the percentage of points scored.2
This may not be surprising given the clinical requirements of the domain (Table 1), particularly the need for pulmonary function tests to diagnose and monitor patients and for staff training to interpret results.
Nevertheless, there must be some disappointment with these results because COPD is an important condition with a significant impact on workload in primary care.Consultation rates for COPD are between two and four times those for angina.3
Implementing effective patterns of care in general practice will offer clinical benefits for patients, improved work patterns for clinicians and, through the QOF,4 financial benefits to the practice.
Practices will now know how many points they scored for these clinical indicators in the first year of the new contract. It is a good time to review systems and examine areas where full points have not been scored with the aim of improving the service provided and maximising QOF scores for this year.
The key elements to achieving high scores are common to all clinical areas. They include a strong leader (or leaders) who can combine an understanding of the nGMS contract with IT skills, and up-to-date IT infrastructure and the training and motivation to use it. Commitment from every member of the practice team to the contract and to providing accessible services for patients is also paramount.
|Table 1: The clinical indicators for COPD|
|COPD 1||The practice can produce a register of patients with COPD||5|
|COPD 2||The percentage of patients where diagnosis has been confirmed by spirometry including reversibility testing for newly diagnosed patients, with effect from 1 April 2003||5||25%||90%|
|COPD 3||The percentage of all patients with COPD where diagnosis has been confirmed by spirometry including reversibility testing||5||25%||90%|
|COPD 4||The percentage of patients with COPD in whom there is a record of smoking status in the previous 15 months except those who have never smoked where smoking status need be recorded only once since diagnosis||6||25%||90%|
|COPD 5||The percentage of patients with COPD who smoke, whose notes contain a record that smoking cessation advice has been offered in the past 15 months||6||25%||90%|
|COPD 6||The percentage of patients with COPD with a record of FEV1 in the previous 27 months||6||25%||70%|
|COPD 7||The percentage of patients with COPD receiving inhaled treatment in whom there is a record that inhaler technique has been checked in the preceding 2 years||6||25%||90%|
|COPD 8||The percentage of patients with COPD who have had influenza immunisation in the preceding 1 September to 31 March||6||25%||85%|
Patient register – COPD 1
Most practices will have established a register by carrying out searches for drugs and for previously noted diagnoses. QOF data for Greater Manchester (548 practices) and Avon, Gloucestershire and Wiltshire (318 practices), show that both areas achieved more than 99%.1
Many practices may not have found this indicator so easy. Some, like my own, found it difficult to distinguish patients with asthma from those with COPD, and we certainly found previous entries recording diagnosis to be imprecise or inaccurate.
As the indicators require pulmonary function testing for diagnosis and monitoring, we have endeavoured to use this tool as early as possible, in nurse-led respiratory clinics, to improve the accuracy of our patient register.
The NICE COPD guideline provides useful diagnostic pointers, which have helped our nursing staff to make informed judgements about diagnosis.5
The difficulty for clinicians lies in judging the threshold at which to make a diagnosis and enter a patient onto the register.The solution to this may be to take a pragmatic approach and make a note of when the individual has symptoms that require intermittent or regular therapeutic intervention.
There are particular difficulties with asthma patients who smoke. Many of these patients are likely to develop COPD. At some point they may need to switch from the asthma register to the COPD register, and a review of pulmonary function tests will aid this decision and inform therapeutic choice.
Practice prevalence is variable and Scottish figures demonstrate this, with prevalences ranging from 1.4% in Grampian to 2.4% in Greater Glasgow.2 Similarly, early figures from some English PCTs show much lower prevalences in affluent areas, such as Harrow with 0.7%, than in urban industrial PCTs, such as St Helens, where the prevalence is 2.5%.1
An important task for every practice is to compare its prevalence with local figures to ensure that it is identifying patients and maintaining an effective register.
Initial diagnosis – COPD 2 and 3
Clinical indicators in both COPD and asthma introduce the concept of testing pulmonary function.This follows the NICE guideline on management of COPD, and is essential in diagnosing COPD and differentiating it from other respiratory conditions.
To gain points for these indicators practices must have access to a spirometer – either the traditional type or the ‘micro’ version – capable of measuring FEV1. Some practices and PCTs arrange for their patients to attend the local hospital or another local practice to undergo testing. Although this may be helpful for practices it may be less convenient for patients.
Reversibility testing has been a contentious issue and although it is required by the QOF, it is not supported by the NICE guideline on COPD. Typically, reversibility testing is performed by measuring FEV1 before and after a dose of a shortacting bronchodilator. The patient’s inhaler technique can be checked at the same time.
Some practices will look at peak flow variability measured by the patient and charted at home.This is helpful, but not a true measure of reversibility, and in my view does not meet the criteria for these indicators.
Figures for these two indicators for Greater Manchester (72% and 68% respectively) and Avon, Gloucestershire and Wiltshire (85% and 81%) reveal that they were the most difficult to achieve, perhaps because of inherent difficulties in taking the measurements and inexperience in doing so.1 However, reversibility testing may be dropped when the QOF is reviewed.6
Smoking – COPD 4 and 5
Smoking is a critical factor in accelerating clinical deterioration in COPD. As smoking status is an element of many of the clinical areas it should by now be virtually automatic for practices to record such data.
In our practice it occurs on virtually all our clinical templates, and patients must tire of being asked about it. Clearly, most practices seem to be in this position and have achieved high points.
The purpose of recording this information is, of course, to allow interventions to promote and support cessation.
Clinicians can check a box on the computer screen to gain the points here, but in view of its importance deeper engagement is needed. Patients should be offered active support via the local smoking cessation service and nicotine replacement therapy.
FEV1 – COPD 6
Regular monitoring allows the practice to track disease progression, monitor the effects of therapy and decide whether further measures are needed.
The NICE COPD guideline offers a comprehensive review of treatment pathways. Many practices are still coming to terms with arranging spirometric reviews every 2 years, and this is reflected in low scores for this indicator.1 With a year’s experience, practices should be able to improve systems and uptake in the coming year.
Inhaler technique – COPD 7
This is an uncontroversial indicator; most practices will have long experience of checking techniques in patients taking inhaled treatments and should have scored well. Surprisingly,however, in both Greater Manchester (74%) and Avon, Gloucestershire and Wiltshire (82%) there were difficulties.1
Pharmacy colleagues may be able to help in this area, by demonstrating and checking device use. Specialist staff from pulmonary rehabilitation services, which in many places are still under development, can also help, as can community nurses in the case of housebound patients.
It is worthwhile discussing joint working in this way, but careful thought should be given to the best way to capture the information on practice computer systems.
Influenza immunisation – COPD 8
For years, practices have had incentives for carrying out influenza immunisation in COPD patients, and the QOF data show that scores for this indicator were higher than for the parallel indicator in the asthma domain. This may be because many patients with COPD have regular contact with their practices and are perhaps better informed about the benefits of influenza vaccination.
Some innovative practices are capitalising on the patient’s visit for flu immunisation and capturing information for a range of domains.
Many patients with COPD will be under joint primary and secondary care, and hospital colleagues often undertake much of the follow up work in patients who are less well.
Relevant data should be gathered from clinical communications and entered onto the GP clinical record to avoid duplication of activity. The practice should have a clear protocol for this procedure.
Exception reporting enables the practice to exclude the data of patients who refuse review or treatment and of those for whom review would be inappropriate because of other medical conditions, frailty or age. However, it is important to consider carefully when it is appropriate to do this.
QOF data show that exception reporting in the COPD indicators is generally low.Exceptions for influenza vaccination (COPD 8) were, not surprisingly, significant, and may reflect the fact that patients had concerns about vaccination.
Some patients with COPD are housebound or live in care homes; respiratory monitoring is difficult in these individuals, so exception reporting could legitimately be employed.
However, a word of caution: PCOs may examine data more closely from any practice that deviates significantly from local patterns of exception reporting.
Success in the COPD indicators depends on developing a systematic approach to patient care.An accurate register must first be established by taking a thorough history and using spirometry to confirm diagnosis. Then, regular reviews should aim to minimise risk factors and offer tailored treatment as well as influenza vaccination.
It is important for the primary healthcare team to undergo regular training. A robust call and recall system is required, and computer templates should be developed or perhaps sourced from colleagues through a computer user group.
The strategy should be backed by a thorough knowledge of the relevant parts of the NICE guideline on the management of COPD.This guideline is likely to inform the QOF review.
- QMAS Database. Health and Social Care Information Centre. London 2005.
- Scottish Health Statistics.General Medical Services Quality and Outcomes Framework data for Scotland. 27 May 2005. www.isdscotland.org.
- COPD Guidelines Group of the Standards of Care Committee of the BTS. Thorax 1997; 52(Suppl 5): S1-S28.
- Investing in General Practice.The New General Medical Services Contract. www.bma.org.uk.
- National Institute for Clinical Excellence. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. NICE Clinical guideline 12. London: NICE, 2004.
- Joint Submission to Quality Review Team. NICE/NHS Quality Improvement Scotland. August 2005.